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Institutional Logics in Continuous

Improvement:

MASTER THESIS WITHIN: Business Management NUMBER OF CREDITS: 15

PROGRAMME OF STUDY: Engineering Management SUPERVISOR: Jonas Dahlqvist

AUTHOR: Robin Vree

Alexander Hutchings JÖNKÖPING May 2017

A study of nurses’ involvement in healthcare change.

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Acknowledgements

We would like to acknowledge the assistance of several people with this thesis.

Firstly, we would like to thank our supervisor Jonas Dahlqvist for his support and criticism. We are grateful to Annika Nordin from the Jönköping Academy at Jönköping University for shaping our research purpose and her efforts in helping us to find participants.

We would also like to thank Göran Henriks from Qulturum, an agency of Jönköping Län, for his enthusiasm about our topic and helping us to access participants in the Jönköping Län healthcare system.

Special thanks for Vilbert Soleymanian for sharing his passion of healthcare and his ongoing effort to improve the quality for patients.

Lastly, thanks to all the respondents for taking the time to help us gather data, allowing us to contribute to further discussion about improving healthcare.

Pleasant reading!

Jönköping, May 2017

Robin Vree Alexander Hutchings

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Master’s Thesis in Business Management

Title: Institutional Logics in Continuous Improvement: A study of nurses’ involvement in healthcare change.

Authors: Robin Vree Alexander Hutchings Supervisor: Jonas Dahlqvist Date: 22-05-2017

Key words: Change Management, Professional Project, Continuous Improvement, Institutional Change, Patient Centric

Abstract

Problem: Continuous improvement is important in modern healthcare to control increasing costs and fulfil the demand for higher quality. This requires interdisciplinary collaboration between healthcare professionals. However, these professions are seeking to maintain and improve their social status through a ‘professional project’. There are existing professional barriers based on historical privileges and boundaries, leading to nurses holding lower status. The extent to which this motivates medical professionals and nurses in particular to be involved in continuous improvement is unclear. Is it that nurses are driven to become involved in continuous improvement by their ‘professional project’, and is there any evidence that involvement in continuous improvement benefits their status?

Purpose: This thesis explores (a) the effect that the ‘professional project’ of nursing, gaining relative equality with doctors, has on involvement in continuous improvement activities, and (b) how involvement in continuous improvement activities affects the status of nurses relative to doctors.

Method: This qualitative study has been performed through an interview study based on themes, on the topic of improvement in healthcare. The empirical data is gathered through semi-structured interviews conducted with professionals from Sweden, New Zealand and The Netherlands. The participants were active within Hospitals and Primary Care, and had the position of nurse, manager or doctor. Data was analysed using the Thematic Analysis approach as proposed by Braun & Clarke (2006).

Findings: The results of our research suggest that nurses’ status has certainly improved. However, rational status-seeking described by many other researchers, could be better described as ‘seeking a voice’. Nurses are driven by ambition and improving patient care, rather than seeking strict equality with doctors. Continuous improvement has given nurses the opportunity to take on more technical roles and have more input on the way medical tasks are conducted. Enhanced communication between all levels of healthcare organisations has given nurses the opportunity to show their knowledge. It has resulted in more understanding and respect by doctors of what nurses are capable of. Nurses are highly motivated to participate in continuous improvement, driven by the common logic of patient centricity. However, external factors such as limited time and financial support slow them down.

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Table of Contents

Acknowledgements i Abstract ii Figures v Tables v Appendices v 1 Introduc:on 1

Background 1

1.1.1 Con9nuous Improvement 1 1.1.2 Con9nuous Improvement in Healthcare 1 1.1.3 Inter-professional Rela9onships in Healthcare 1 1.1.4 Changing Professional Roles in Healthcare 2

Problem 3

Purpose 4

2 Theore:cal Framework 5

Con7nuous Improvement 5

2.1.1 The Lean Methodology 5 2.1.2 The Six-Sigma Methodology 6 2.1.3 Con9nuous Improvement in Healthcare 6

The Nature of Professions 6

2.2.1 Defining Profession 6 2.2.2 The Goal of Professions 7

Iden7ty and Professions 7

2.3.1 Professional Iden9ty 7 2.3.2 Team Iden9ty 8

Change Management 8

2.4.1 Leaders’ Roles and Employee Par9cipa9on in Change Processes 8 2.4.2 Change Management in Healthcare 9

Ins7tu7onal Theory 9

2.5.1 The Nature of the Ins9tu9on and Ins9tu9onal Work 10 2.5.2 Ins9tu9onal Change and Ins9tu9onal Entrepreneurship 13 2.5.3 Mul9ple Ins9tu9onal Logics 13 2.5.4 The Ins9tu9ons of Professions 14 2.5.5 Predecessors: Func9onal and Power Theories 14

A Model of Professional Change 15

Bringing Together Ins7tu7ons and Professions 16

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3 Research Method 18

Research Design 18

Research Philosophy 18

Techniques 19

3.3.1 Data Collec9on 20 3.3.2 Case Selec9on 20 3.3.3 Interviews 21 3.3.4 Data Analysis 22

Quality 23

3.4.1 Credibility 24 3.4.2 Transferability 24 3.4.3 Dependability 24 3.4.4 Confirmability 25

Ethics 25

4 Results 27

Interviewees’ Experiences with Con7nuous Improvement 27

Theme 1: Job Sa7sfac7on 27

Theme 2: Professional Boundaries 28

Theme 3: Underlying Change 30

Theme 4: Professional Interac7on 32

5 Analysis 34

Thema7c Analysis 34

5.1.1 Theme 1: Job Sa9sfac9on 35 5.1.2 Theme 2: Professional Boundaries 36 5.1.3 Theme 3: Underlying Change 37 5.1.4 Theme 4: Professional Interac9on 38

The Professional Project 39

Change Acceptance 39

The Ins7tu7ons of Medicine 40

Conclusions 40

5.5.1 A Model of Professional Change 41 6 Discussion 43

The Relevance of this Study 43

6.1.1 The Logic of Pa9ent Centricity 44 6.1.2 The Doctor-Nurse Game 44

Management Implica7ons 45

Limita7ons 45

Future Research 46

References 47

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Figures

Figure 1 – Reasons Change Programs Fail (Giniat et al., 2012, p. 85) 8 Figure 2 – A Model of the Main Tasks and Roles of Nurse-Leaders During a Change Process

(Salmela et al., 2012, p. 429). 9

Figure 3 – The Institutionalisation Curve. From Jennings and Greenwood (2003, p. 196),

with modification after Scott (2008a). 12

Figure 4 – A Model of Professional Change 15

Figure 5 – Model of Qualitative Research Design (Meyers, 2008) 18 Figure 6 – The Thematic Analysis Process (Braun & Clarke, 2006, pp. 17–23;

Easterby-Smith et al., 2015, p. 191) 23

Figure 7 – The Thematic Analysis Process 34

Figure 8 – Themes from Thematic Analysis 35

Figure 9 – An Updated Model of Professional Change 42

Tables

Table 1 – Interview Participants 21

Appendices

A. Definitions

B. Interview Topic Guide C. Ethical Considerations D. Codes and Themes

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1 Introduc;on

Change is often challenging, but change drives growth. If we were to resist change then neither the computer this was typed on, nor the learning institution it was completed at would exist. Change leads to uncertainty, and we must convince people of the benefits and need for change. Understanding why people become involved in change is important in driving change to improve efficiency and effectiveness. This study investigates one particular environment of change involvement, nurses in healthcare change.

Background

1.1.1 Con;nuous Improvement

Continuous improvement and innovation have received significant focus in public sector organisations for some time. The main purpose of continuous improvement is to implement “improvement initiatives that increase successes and reduce failures” (Bhuiyan & Baghel, 2005, p. 761). High levels of quality can be achieved in an organisation through a process of continuous pursuit of improvement and involvement of all levels (Bhuiyan & Baghel, 2005, p. 761). Lean and Six-Sigma are the approaches most often used for continuous improvement (D’Andreamatteo, Ianni, Lega, & Sargiacomo, 2015, p. 1205). Lean is a methodology that seeks to systematically identify and eliminate waste in pursuit of perfection. Six-Sigma is a statistical control methodology which measures and reduces process deviation from a desired mean (Carter, 2010, p. 508). Minimising errors to close to zero is the heart of the Six-Sigma methodology (Bhuiyan & Baghel, 2005, p. 763) and creating an inter-professional work community is essential to achieve this.

1.1.2 Con;nuous Improvement in Healthcare

In healthcare, continuous improvement is also called quality improvement or simply improvement. Continuous improvement methodologies have been adopted in an attempt to improve efficiency and control ever-increasing costs (Kollberg, Dahlgaard, & Brehmer, 2007, p. 7; Radnor & Walley, 2008, p. 13; Stanton et al., 2014, p. 2927). Continuous improvement initiatives have not been universally successful in healthcare (Mazzocato, Savage, Brommels, Aronsson, & Thor, 2010, p. 381; Radnor, Holweg, & Waring, 2012, p. 369; Young & Mcclean, 2008, p. 383). Nurses and doctors differ in the way they think about improvement work (N. Eriksson et al., 2016, p. 88) and hierarchy and status differences between them hinder the process (Mazzocato et al., 2010, p. 380). There is significant interest in continuous improvement methodologies in healthcare, due to the good results reported by some (de Souza, 2009, p. 122).

1.1.3 Inter-professional Rela;onships in Healthcare

Healthcare is an industry comprised of inter-professional relationships. Professional groups involved in healthcare include doctors, nurses, healthcare managers and a myriad of other medical professionals such as psychologists and social workers. When analysing continuous improvement programs, it is most useful to concentrate on the physician, nurse, manager interaction, as these are the most numerous of the professional groupings. Indeed, other groups are often marginalised in professional interactions (Suddaby & Viale, 2011, p. 435). The relationship between doctors and nurses has a long history and has generally characterised by Stein’s doctor-nurse game. First described in by Stein in 1967, the game involves the nurse playing a subservient role and offering advice to the doctor in a carefully disguised way (Stein, Watts, & Howell, 1990, p. 546). While the game has changed over time, primarily as a result of increased nursing education (Stein et al., 1990, p. 547; Svensson, 1996, p. 397), the medical profession is still dominated by doctors (N. Eriksson et al., 2016, p. 90; Stein et al., 1990, p. 546). Factors such as gender, age, and level of education of the nurse or

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physician also directly impact the level of collaboration (Fewster-Thuente & Velsor-Friedrich, 2008, p. 40). Change has not been purely due to changes in society, it has been the ‘professional project’ of nurses in many countries to establish themselves as the professional equals of doctors (N. Eriksson et al., 2016, p. 90; Salhani & Coulter, 2009, p. 1223; Stein et al., 1990, p. 547). The nursing profession has an interest in disrupting existing institutional structures to advance their agenda. This is not necessarily a zero-sum game, while the goal is to gain equal status (Stein et al., 1990, p. 547), it is not always at the expense of others, although it can be (Salhani & Coulter, 2009, p. 1227). However, most employees in each profession agree that inter-disciplinary teams benefit patients (Leipzig et al, 2002, p. 1141). The professional healthcare manager and their relationship with other healthcare professions has a much shorter history. While there has been a push towards greater efficiency since at least the 1970’s (Radnor, Holweg, & Waring, 2012, p. 364), the role of healthcare manager has grown in prominence since the mid-1990’s through structural changes to the healthcare system such as New Public Management in the United Kingdom (Radnor et al., 2012, p. 364) and similar changes in Sweden (Hellström, Lifvergren, & Quist, 2010, p. 502). The relationship between clinical staff and managers has often been poor, with authors in Sweden, the United Kingdom and the Netherlands all reporting conflict based on differing view (Currie, Lockett, Finn, Martin, & Waring, 2012; Hellström et al., 2010; van den Broek, Boselie, & Paauwe, 2014). In general healthcare managers are said to be outwardly more concerned with corporate interests such as efficiency and budgetary matters and clinical staff with patient outcomes (van den Broek et al., 2014, p. 10). However healthcare managers attempt to communicate these matters as being mutually beneficial, claiming that, for example, increased efficiency will result in more time and resources being directed to patient care (van den Broek et al., 2014, p. 12; Waring & Bishop, 2010, p. 1335). Regardless of inter-professional conflicts it is clear that healthcare managers now possess a lot of power.

1.1.4 Changing Professional Roles in Healthcare

Much has changed over the past decades in the inter-professional relations; nurses are more highly educated, doctors are increasingly to be female, there is more respect for people and their knowledge, better teamwork and communication (Chua & Clegg, 1990, pp. 155–162; Stein et al., 1990, p. 546). Many medical organisations have been turned into enterprise-like organisations, which has led to the use of managerial tools related to finance and efficiency, and organisational tools related to quality and safety (Correia, 2013, p. 255), often driven by the struggle with rising costs. This brings changes in roles and levels of autonomy and has seen the rise of new professions. Two ongoing changes are seen as particularly significant (Correia, 2013, p. 255), one is the changing relationships with governmental organisations, other health professionals and the patients, the other is changes of professional roles and organisations. Managers have been made increasingly responsible for ensuring that political decisions are implemented in public organisations (Correia, 2013, p. 261). Professional managers are expected to play a crucial role in these operations as they link government funding to medical professionals’ behaviour (Correia, 2013, p. 255). But sometimes the interactions between the medical profession and hospital management causes conflicts. This is often the result of medical professionals and management pursuing opposing interests and rationales (R. McDonald, Campbell, & Lester, 2009, p. 1211). Partly this is because doctors will not accept any interference from their peers or the hospital management and similarly do not want to know what is being done in other groups (Correia, 2013, p. 264).

Nurses have made large changes in the modernisation of their profession over the last decades. Almost all nurses interviewed by McDonald (2009, p. 1209) reported that their roles had changed, which led to increased responsibility. Nurses are doing work which had previously been only undertaken by doctors (R. McDonald et al., 2009, p. 1206). This is a major shift away from the traditional role of working as “handmaidens” to doctors (R. McDonald et al., 2009, p. 1210). Some nurses have extended their role to areas in which they are not necessarily formally qualified (R. McDonald et al., 2009, p. 1207). Most nurses have actively embraced

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new ways of working, this has increased job satisfaction, but has also placed many nurses under increased pressure. For example, most nurses are reluctant to engage in diagnosis, appearing to view this as a step into medical, as opposed to nursing, territory (R. McDonald et al, 2009, p. 1210). Nursing is a job which is perceived as being routine and ‘template-driven’, this conflicts with the perceived attributes of professions and may limit nurses’ claim to professional status (R. McDonald et al., 2009, p. 1206). Nurses’ claims to be members of a profession are also affected by gender and expectations. In particular, part-time nurses may be seen as inferior to the full-time nature of other professions (Ozbilgin, Tsouroufli, & Smith, 2011, p. 1588). Nurses may be unwilling to take on extra responsibility for which they do not receive extra pay or other reward (R. McDonald et al, 2009, p. 1210) and this may influence involvement in improvement processes.

Problem

While continuous improvement methodologies promise much for the healthcare industry they have not consistently delivered verifiable results (de Souza, 2009, p. 122; Dellifraine, Langabeer Ii, & Nembhard, 2010, p. 223; Young & Mcclean, 2008, p. 383). Studies into the difficulties faced in implementing continuous improvement in healthcare have identified barriers including difficulties in defining ‘value’ (Radnor et al., 2012, p. 368; Young & Mcclean, 2008, p. 384), failure to take a long-term view but instead preferring ‘quick wins’ (de Souza & Pidd, 2011, p. 62; Mazzocato et al., 2010, p. 381; Radnor et al., 2012, p. 370), ingrained habits of staff (Nilsen, Roback, Broström, & Ellström, 2012, p. 1) and conflict stemming from the professional nature of the healthcare organisation (Currie et al., 2012; N. Eriksson et al., 2016, p. 90; Waring & Bishop, 2010, p. 1339). These inter-professional conflicts arise from the multiple professional viewpoints or institutional logics existing in healthcare organisations (Salhani & Coulter, 2009; van den Broek et al., 2014, p. 10). Several authors have identified professional managers, doctors and nurses as possessing differing institutional logics within the healthcare organisation (Currie et al., 2012; N. Eriksson et al., 2016; van den Broek et al., 2014, p. 10). While well-identified, how these differing institutional logics contribute to the success or failure of continuous improvement efforts remains an underexplored area (N. Eriksson, 2017, p. 80; N. Eriksson et al., 2016, p. 90). To explore this area a good understanding of the context is required.

Continuous improvement is an inherently disruptive process, it challenges existing order in the search for reduced waste and improved quality (Waring & Bishop, 2010, p. 1332). Challenges to the power and status of a profession leads to a reaction against the change in order to maintain professional power (Currie et al., 2012, p. 940). This is seen in Waring and Bishop’s (2010, p. 1337) ethnographic study of Lean implementation in an NHS hospital through the “resistance” actions taken by staff members and echoed as the “ceremonial adoption” of Lean by nurses in van den Broek’s study of a Dutch Hospital (2014, p. 17). Resistance also takes place though intra-professional means such as papers in academic journals, for example the denunciation of “Medical Taylorism” by Hartzband and Groopman (2016, pp. 106–108) in the New England Medical Journal. However, reaction to organisational change is not always negative, with some embracing continuous improvement driven change. Several authors have claimed that this can be brought about by opportunities to advance personal or professional agendas (N. Eriksson et al., 2016, p. 90; Stanton et al., 2014, p. 2929; Waring & Bishop, 2010, p. 1339). Other possible involvement drivers include continuous improvement matching existing professional logics, for example in having strong patient focus (N. Eriksson et al., 2016, p. 89; Waring & Bishop, 2010, p. 1335) or having a personal interest in the process and practice of continuous improvement (Waring & Bishop, 2010, p. 1336). While continuous improvement challenges existing orders, and can result in a negative reaction, this is not always the case. Involvement in continuous improvement can be, but is not necessarily, driven by a desire to advance personal or professional goals. One well documented professional goal in the healthcare setting is that of the nursing profession to advance its professional standing.

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Nurses and doctors are central in improving the quality of care, minimising errors in their practices, and using scarce resources effectively (N. Eriksson et al., 2016, p. 85). This improvement work is often carried out in team-based structures where different professional groups are involved. Leipzig et al. (2002, p. 1141) argue that five variables are fundamental to effective medical teamwork: definition of appropriate goals, clear role expectations for members, a flexible decision-making process, the establishment of open communication patterns and leadership. Unfortunately, the fact is that healthcare teams are very often do not effectively create this environment. Research by West and Lyubovnikova (2013, p. 135) shows that 70 percent of medical errors can be attributed to poor teamwork. The absence of clear patterns of communication and good information are often the main barriers. Furthermore, collaboration often involves letting go of old identities and the security and self-identity that come with them (Campbell, 2008, p. 34).

It is the goal of the nursing profession to improve their professional standing and professionals are known to use continuous improvement activities to advance professional agendas. Eriksson found that nurses considered continuous improvement “career enhancing” (2017, p. 77), but there is little direct evidence that continuous improvement is used to advance the professional project of nursing. Furthermore, while several authors have proposed reasons for the narrowing status gap between doctors and nurses (Stein et al., 1990, pp. 564–547; Svensson, 1996, pp. 383–386), only Eriksson (2016, p. 90) proposes involvement in continuous improvement work as one of these factors. This leads to the questions, do nurses use continuous improvement to advance their goal of improved status? And has involvement in continuous improvement affected their status?

Continuous improvement in healthcare has faced obstacles to its success. One of these is inter-professional conflict stemming from the multiple institutional logics present. These multiple institutional logics are a result of the multiple professions involved in delivering healthcare. Historically the prevailing relationship in healthcare has been doctors in charge, everyone else, and nurses in particular, serving. Nurses have been somewhat, but not completely, successful in their professional goal of increased status and equality with doctors. Another important relationship is that of the healthcare manager with medical staff. This relationship has evolved over the last few decades in response to demands for greater efficiency in healthcare. Understanding why different professions are motivated to take part in continuous improvement activities is important, these activities have been shown to be effective in improving both efficiency and patient outcomes. If nurses are indeed interested in continuous improvement programs as they help advance claims for higher status, then this will help managers in gaining support for these activities and managing resistance from other professions who may perceive this involvement as a threat.

Purpose

This thesis explores (a) the effect that the ‘professional project’ of nursing, gaining relative equality with doctors, has on involvement in continuous improvement activities, and (b) how involvement in continuous improvement activities affects the status of nurses relative to doctors.

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2 Theore;cal Framework

This section lays out theories relevant to the purpose of this thesis. These theories will be used later in analysing the empirical data.

Continuous improvement methodologies have been used for some time in healthcare, but they have not always been successful. One main reasons given for this is conflict between the professions. The concept of professions is hard to pin down, however an understanding of the nature of the professions and how they interact in organisational change is important to understanding the involvement drivers of nurses in relation to continuous improvement. Professional self-identity is important for professionals, but it can create in- and out-groups which can frustrate the teamwork required for effective change. Looking at the problem from another angle, change management provides concepts which can also explain the actions of professions in relation to continuous improvement. The creation and actions of professional groups can be explained through institutional theory. Institutions provide professions with the frameworks for interacting with other groups. However, explaining change within institutions requires the introduction of the theory of Institutional Entrepreneurship.

Con;nuous Improvement

Continuous improvement methodologies tackle the problem of process inefficiency (Bhuiyan & Baghel, 2005, p. 761). While they accomplish this from different viewpoints, they all work to the same end (Andersson, Eriksson, & Torstensson, 2006, p. 284). There are a number of varieties of continuous improvement including Lean, Six-Sigma, Total Quality Management (TQM) and combinations such as Lean-Six-Sigma (Bhuiyan & Baghel, 2005, p. 762; Suárez -Barraza, Ramis-Pujol, & Kerbache, 2011, p. 296). These approaches also differ in their view on employee involvement. The two most popular types, Lean and Six-Sigma (D’Andreamatteo et al., 2015, p. 1205) are described below.

2.1.1 The Lean Methodology

The Lean continuous improvement methodology is commonly associated with the Toyota Production System (Holweg, 2007, p. 420), however in reality it is the continuation of a number of previous improvement systems. These include the produktionstakt or touch-time concept developed by Focke-Wulff prior to World War 2, Henry Ford’s production-line approach and post-war American automobile manufacturing techniques (Holweg, 2007, pp. 421–422). Closely associated with Lean is the concept of Kaizen or continuous-improvement-drive, this introduces elements of the human-resources school of management, in particular the focus on employees as contributors to change (Suárez-Barraza et al., 2011, p. 290). Lean was popularised by Henry Beam’s book ‘The Machine that Changed the World’, which first used the term “lean production” (Hines, Holweg, & Rich, 2004, p. 995). Beam communicated Lean in an accessible way, contributing to its popularity (Holweg, 2007, p. 430). In general, Lean is concerned with the elimination of waste, or muda, to optimise the production system (Bhuiyan & Baghel, 2005, p. 763). Waste is anything that does not contribute to value for the customer (Hines et al., 2004, p. 997). A number of attractive-sounding waste-reduction frameworks have been developed around Lean, including 5S and Kanban (Leseure, 2010a). Lean has been criticised for its focus on local improvements over holistic considerations and ignorance of the human aspects of productions (Hines et al., 2004, p. 1000). Indeed at Toyota, focus on optimising one aspect, production-line speed, resulted in health and safety conditions that would be unacceptable by American or European standards (Mehri, 2006, p. 25). Excessive application of Lean principles can risk stifling innovation and overall productivity through focus on smaller and smaller efficiencies rather than the whole (Mehri, 2006, p. 27). However, Lean remains a popular methodology, perhaps due to its simple messages.

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2.1.2 The Six-Sigma Methodology

Six-Sigma is a statistical quality control methodology aimed at reducing the variation of a sample to close-to-zero (Leseure, 2010b, p. 189). The name Six-Sigma refers to the goal of having six standard deviations fall within the acceptable bounds of the process, this would result in 3.4 defects per million. It was originally developed at Motorola (Bhuiyan & Baghel, 2005, p. 763), and owes its origins to a number of preceding frameworks, including total quality control and zero-defect culture (Leseure, 2010b, p. 189). A key concept in Six-Sigma is the DMAIC loop: Define, Measure, Analyse, Improve, Control (Leseure, 2010b, p. 189). This decision-making loop is essentially the same as Deming’s PDCA cycle: Plan, Do, Check, Act (Leseure, 2010b, p. 189). Six-Sigma is primarily criticised for being Total-Quality Management (TQM) re-badged (Andersson et al., 2006, p. 288; Schroeder, Linderman, Liedtke, & Choo, 2008, p. 537). The tools involved are little-different from other statistical quality control methodologies (Schroeder et al., 2008, p. 537), and it is seen to suffer the same high failure rates and difficulties in understanding the field as TQM (Andersson et al., 2006, p. 286). Much like Lean, Six-Sigma seeks to use the stereotype of Japanese efficiency, through the use of a karate-belt style hierarchy of training (Andersson et al., 2006, p. 287). Six-Sigma differs from Lean in that it holds that only a percentage of employees should be provided the training and be able to enact change (Leseure, 2010b, p. 190), and is thus a more top-down approach.

2.1.3 Con;nuous Improvement in Healthcare

While continuous improvement methodologies have been used in healthcare since the 1930’s, there remains significant room for improvement in healthcare quality (Dellifraine et al., 2010, p. 211). The Lean methodology first appears in healthcare literature around 1995, and is closely associated with efforts to save money (de Souza, 2009, p. 123). Six-Sigma appears in literature around 1999 (Dellifraine et al., 2010, p. 214). The “efficiency agenda” is not, however, new (Radnor et al., 2012, p. 364). While many methodologies, including TQM and Business Process Re-engineering (BPR), Lean and Six-Sigma are two of the most popular (Dellifraine et al., 2010, p. 212), with Lean being the most popular (Radnor et al., 2012, p. 364). However, despite many “success stories” being presented, it is often hard to find evidence of the effectiveness of continuous improvement in healthcare (de Souza, 2009, p. 122; Young & Mcclean, 2008, p. 383). Most literature on Lean in healthcare fails to provide concrete evidence of success or failure of initiatives (de Souza, 2009, p. 131).

Professional relations are claimed to be a significant barrier to successful implementation of continuous improvement programs in healthcare (Mazzocato et al., 2010, p. 380). Developing a culture that creates the involvement of everyone in the organisation, which is critical for the implementation of Lean and Six-Sigma (Radnor & Walley, 2008, p. 14), is not without challenges. Healthcare organisations have sought to involve everyone in improvement activities and reduce the hierarchical nature of the relationships between doctors and other staff (Hung, Martinez, Yakir, & Gray, 2015, p. 106). However, there still remains differences between the way nurses and doctors look at how continuous improvement processes are implemented (N. Eriksson et al., 2016, p. 88).

The Nature of Professions

2.2.1 Defining Profession

Defining professions has been a difficult task for researchers (Evetts, 2013, p. 779). Traditionally, the essence of a profession is said to be having unique or special knowledge and a self-imposed obligation to serve, as well as involvement in professional organisations (Leicht & Fennell, 2014, p. 432; Muzio, Brock, & Suddaby, 2013, p. 702). Professions can also be viewed as a way of organising and controlling work, distinct from bureaucracies and market organisations (Evetts, 2013, p. 781; Freidson, 2001, p. 1). The work organisation of professions is based on the autonomy of organised expert groups that by themselves decide on the

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principles and procedures of their activities (Freidson, 2001, p. 425). While these characteristics are not mutually exclusive, they do not provide a definition of which groups are and which groups are not professions.

The archetype of the professions are the Anglo-American medical and legal professions as they existed at the start of the twentieth century (Abbott, 1988, p. 4). However, the definition has been expanded significantly over time. Some authors have attempted to enumerate professional fields, whereas others detail traits and behaviours. Leitch and Fennell (2014, p. 432), for example, use a three-point definition invoking concepts of freedom from oversight except oversight by professional peers, expert knowledge and occupational control. Abbott (1988, p. 35) builds a definition based on the kinds of work undertaken by professionals. Precise definitions are not always helpful in advancing understanding, all definitions have identifiable exceptions, so most researchers do not exhaustively define the professions any longer (Evetts, 2013, p. 779). It is generally agreed that professions apply knowledge to the management of special cases and entry to professions requires a period of specialised training (Abbott, 1988; Evetts, 2015, p. 397; Freidson, 1989, p. 425). Examples of professions include doctors, lawyers, professors, accountants, pharmacists, engineers, teachers and nurses (Evetts, 2013, p. 778; Leicht & Fennell, 2014, p. 432).

2.2.2 The Goal of Professions

Historically the goal of professions has been described an occupational group seeking improved social stature and market monopoly through a ‘professional project’ (Evetts, 2015, p. 402). This has been seen by some authors as the only goal of professions, however interpretations have moved away from seeking complete monopoly to a focus on public legitimacy (Evetts, 2015, p. 402). The concept of the ‘professional project’ emphasises a coherent and consistent course of action towards the goal of social mobility (K. McDonald, 1995). The term ‘professional project’ has been used in more broad terms by authors to describe groups seeking legitimacy for their claims to new or expanded professional status. Salhani (2009, p. 1221) uses these broad terms describing ‘professional projects’ in the field of medicine, saying “all health professions… are relentlessly pursuing their various professional projects” seeking “consolidated [or] expanded professional boundaries” and for “self-governance, particularly in reference to professional work autonomy”. The broad definition of the ‘professional project’ allows analysis to move away from solely selfish and domination-focused view of professional projects to one which emphasises purposeful work to improve professional position. At its heart, the professional project involves change.

Iden;ty and Professions

2.3.1 Professional Iden;ty

An important part of a profession is the self-identity of its members (Mitchell, Parker, & Giles, 2011, p. 1325). Professional identity is one of the many social identities held by professionals (Hotho, 2008, p. 729). Social identities help individuals to identify where their place in society is (Hogg & Terry, 2000, p. 123). Professional identity is associated with “a sense of common experiences, understandings and expertise, shared ways of perceiving problems and their possible solutions” (Evetts, 2013, p. 134). Professional identity provides a sense of stability and belonging, and reduces ambiguity (Hotho, 2008, p. 729). These identities are created by a process of constant comparison between the in-group and out-group which seeks to establish differentiation between groups and a sense of superiority (Hogg & Terry, 2000, p. 124). Challenges to in-group superiority are met with group reactions (Currie et al., 2012, p. 938; Mitchell et al., 2011, p. 1326).

A changing professional identity is that of doctors. This has led to a loss of the stability and belonging that this identity previously provided. Historically identifying as a professional doctor gave members greater independence of work (R. McDonald et al., 2009, p. 1210). However, this has changed over time. The values of autonomy and independence historically

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valued by doctors are being challenged by greater emphasis on efficiency (Suddaby & Viale, 2011, p. 427). Now, many senior doctors feel a sense of nostalgia due to changes which have reduced the ‘heroic’ view of the doctor (Ozbilgin et al., 2011, p. 1591).

2.3.2 Team Iden;ty

Modern business pressures and the complexity of projects lead to problems being unable to be solved by single-specialisation groups (Mitchell et al., 2011, p. 1322). A diverse team is more likely to achieve positive results (Williams & O’Reilly, 1998). However, professions’ specialist knowledge is often not shared across professional boundaries (Mitchell et al., 2011, p. 1324). The individual identity as a member of a profession can result in teams which share a weak sense of team identity. These teams will instead focus on professional identity, biases and stereotypes (Mitchell, et a, 2011, p. 1327). Members of teams with strong team-based identities, conversely show reduced out-group bias to the other groups in the team (Mitchell et al., 2011, p. 1326).

Change Management

The drive towards more efficient, effective healthcare organisations has caused significant organisational change. It is the task of managers to move an organisation from its present state to a desired future state, they must manage change (Kim, Hornung, & Rousseau, 2011, p. 1330). Change is a complex phenomenon, factors such as underlying world-views and employee reactions greatly affect change implementation (Salmela, Eriksson, & Fagerström, 2012, p. 424). Change management is a variety of different practices which “facilitate the enactment of organizational change processes” (Raineri, 2011, p. 266).

2.4.1 Leaders’ Roles and Employee Par;cipa;on in Change Processes

Leadership is critical in the success of change processes and the management of ‘people-issues’ is a critical task for leaders (Giniat, Benton, Biegansky, & Grossman, 2012, p. 85). Leadership is process of providing direction, shaping an environment which provides motivation and allows resources to be transformed into the fulfilment of goals (Salmela et al., 2012, p. 424). Engaging and motivating the entire workforce significantly benefits change processes (Giniat et al., 2012), but this requires leaders to adopt many leadership styles and fill many roles to shape and change attitude and values (Salmela et al., 2012, p. 429). Leaders must orchestrate interdisciplinary teams to achieve successful change (Salmela et al., 2012, p. 424). The importance of good leadership in change processes is showed by the research of Giniat, et al (2012, p. 85); although 70 percent of all business initiatives fail to meet their objectives, of those that do, 90 percent attribute their success to transitioning their people in the right way. The reasons given by Giniat et al. (2012, p. 85) for failure of change processes are shown in Figure 1. Many of these can be related to the leadership functions discussed above.

Reasons change programs fail Resistance to change 62% Limita9ons of exis9ng systems 43% Lack of execu9ve commitment 41% Unrealis9c expecta9ons 38% Lack of cross-func9onal team 24% Inadequate team and user skills 22% Technology users not involved 21%

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Employee involvement is instrumental in accomplishing change objectives (Kim et al., 2011, p. 1669). Identifying factors which motivate individuals is important to ensure that change is supported and successful (Kim et al., 2011, p. 1669). However, employees are often more comfortable following than leading change. Understanding the need for change comes first, employees must understand the context of change and agree with the need for change in order to successfully enact it (Campbell, 2008, p. 33). According to Fisher (1993) reducing the resistance by the participants to change can be accomplished by appealing to their interests and aspirations using terms familiar to them. For instance, providing more autonomy in decision making may appeal to employees (Kim et al., 2011, p. 1671). However, employees are also motivated by the social norm of reciprocity (Kim et al., 2011, p. 1672). Engagement is more likely where leaders and employees have high-quality relationships (Kim et al., 2011, p. 1672). Credibility and trust for the change can be achieved by working with employees perceived as trustworthy and credible themselves (Campbell, 2008, p. 34). Supporting employee sense-making and sense-giving by management, especially at the start of change, is essential for success (Kim et al., 2011, p. 1689). Some continuous improvement methodologies such as Lean stress the importance of employee involvement (Hung et al., 2015, p. 104).

2.4.2 Change Management in Healthcare

In healthcare, there is an ongoing implementation of new services, processes and policy. Nurses play an important role in this process. During the last decade nurses have experienced many organisational changes (Salmela et al., 2012, p. 430). A special role in change management is held by ‘nurse-leaders’ (Salmela et al., 2012, p. 430). Salmela et al. (2012, p. 431) argue that nurse-leaders need guidance during change processes, this guidance allows them to determine what is required to enact successful change. Nurse-leaders must not only maintain high-quality care, but also lead change, including financial, process and personnel issues (Salmela et al., 2012, p. 423). Figure 2 shows the elements that must be balanced by medical change leaders. Salmela, et al. (2012) contend that leaders need to utilise various leadership styles to maintain a balance between these three aspects.

Ins;tu;onal Theory

The dominant theory for framing the actions of professions is institutional theory (Leicht & Fennell, 2014; Muzio et al., 2013). Institutional theory takes a rational view of the interaction

Figure 2 – A Model of the Main Tasks and Roles of Nurse-Leaders During a Change Process (Salmela et al.,

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of organisations and individuals with the self-perpetuating rules, cultural norms, values and beliefs present in a particular field (Clegg, Hardy, Lawrence, & Nord, 2006, p. 217; Hoffman, 1999, p. 352). It stems from the social-constructionist tradition, and considers institutions to be formed and influenced by, but separate from, the individuals which constitute them (Clegg et al., 2006, p. 217). Institutional Theory explains “what is and what is not, what can be acted upon and what cannot” in an organisation (Hoffman, 1999, p. 351). The actions of professional groups and indeed the existence of professions can be explained using institutional theory (Leicht & Fennell, 2014, p. 431; Scott, 2008b, p. 221). Important concepts in institutional theory are the nature of the institution and the work conducted to establish and maintain them, the co-existence of institutions within a larger organisation and how change is enacted in an institution.

2.5.1 The Nature of the Ins;tu;on and Ins;tu;onal Work

The concept of institutions is in some ways an obvious one: we are aware of external constraints on behaviour which vary by situation. However, defining how these exist and how they are created and maintained is somewhat harder. The concept of the institution links the social elements of life to the constraints experienced by organisations and individuals (Clegg et al., 2006, p. 215). Institutions shape the actions of organisations and individuals through shared schemas, beliefs and values that exist in the environment the organisation operates in (Leicht & Fennell, 2014, p. 434). The schemas, beliefs and values are sourced from “key organisational actors” such as managers, important clients and regulators (Leicht & Fennell, 2014, p. 434). Institutions have their own logics, sets of principals which coherently guide the organisation in the social field (Besharov & Smith, 2014, p. 364; Thornton & Ocasio, 2014, p. 100), their own basis for establishing legitimacy and ensuring compliance (Leicht & Fennell, 2014, p. 434; Scott, 2008b, p. 222) and mechanisms of transmission (Leicht & Fennell, 2014, p. 434). Institutional theory has been elaborated significantly since it was first proposed (Leicht & Fennell, 2014, p. 433; Scott, 2008b, p. 222), with additional viewpoints such as economic institutionalism and cognitive institutionalism joining sociological institutionalism (Garud, Hardy, & Maguire, 2007, p. 959) and an increasing emphasis on institutional change rather than enduring static institutions (Clegg et al., 2006, p. 216; Leicht & Fennell, 2014, p. 433).

One ongoing debate in institutional theory is the extent to which purposeful human actions affect institutions. The two accounts of the extent to which they affect institutions are known as the agency account and the naturalistic account (Scott, 2008b, p. 222). The agency account claims that institutions are formed by purposeful work by agents such as individuals or organisations. Key concepts in the agency account are purposefulness and power (Scott, 2008b, p. 222). Conversely the naturalistic account argues that institutions are formed and maintained by “natural and undirected” processes (Scott, 2008b, p. 222). This is not to say that individuals are not involved, but that they are not purposefully driving the process. The agency account is more common in recent literature, for example Scott (2008a, 2008b, p. 222), Clegg (2006, p. 218) and Leicht & Fennell (2014, p. 434) all support this account. The agency account is important in explaining institutional change (Clegg et al., 2006, p. 218), this section will examine institutionalism from an agency account perspective. While often portrayed as black-and-white, it is important to remember that these accounts exist on a spectrum and are not absolutes. The extent to which these accounts are valid is still very much a matter for scholarly debate.

Scott (2008a, 2008b, p. 222) presents framework for understanding how institutions support and enforce their logic, based off of DiMaggio and Powell’s (1983, p. 150) seminal work. In Scott’s (Scott, 2008b, p. 222) framework, three pillars support the institution, (1) the regulative pillar, (2) the normative pillar and the (3) cultural-cognitive pillar. The regulative pillar is the use of coercive power such as legal and regulatory sanctions. The normative pillar introduces ‘appropriate’ behaviour, this influences behaviour by establishing “best and customary” (Leicht & Fennell, 2014, p. 4) ways of acting. Finally, the cultural-cognitive pillar establishes common symbolic systems to guide behaviour. Work towards establishing,

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maintaining and destroying these pillars is referred to as institutional work. Distinct types of institutional work are undertaken in differing phases of an organisations existence, with construction, maintenance and destruction of institutions requiring differing actions (Clegg et al., 2006, p. 222).

The construction of new institutions can be seen as the construction of Scott’s three pillars (Jennings & Greenwood, 2003, p. 197). This takes place through a process of innovation, objectification, legitimation and diffusion as shown below in Figure 3 (Jennings & Greenwood, 2003, p. 196). Innovation is the development of new ideas. However in order to be distributed, it must be expressed in language and thought through objectification and finally gain legitimacy from actors in the field in order to diffuse and be widely accepted (Jennings & Greenwood, 2003). Once it has spread to all of the relevant population, the institution can be described as “fully institutionalised” (Jennings & Greenwood, 2003, p. 196) or “sedimented” (Scott, 2008a, p. 126). Scott (2008a) claims that the same institutional work is used to establish an institution as change and disestablish it and that the distinctions are somewhat arbitrary, however Clegg et al. (2006, p. 221) argues for differentiation between phases. Clegg et al. (2006, p. 223) provides a non-exhaustive list of 10 types of instructional work associated with institutional construction. However these ten types of work are grouped into the same three categories of institutional work proposed by Scott (2008a), coercive, normative and mimetic. While it is tempting to imagine the agents ‘erecting’ each pillar individually, perhaps establishing common symbols and meaning before codifying appropriate behaviours for the institution and finally establishing rules and regulations, the reality is more complex with each act of institutional work affecting each pillar in different ways (Scott, 2008a). Most authors invoke the agency account when describing institutional construction (Clegg et al., 2006, p. 218; Jennings & Greenwood, 2003, p. 196; Scott, 2008a, 2008b, p. 222), however the degree to which institutions are ‘intelligently designed’ during construction is debated. Institutions are created by purposeful work by agents to create and diffuse legitimated regulative, normative and cultural-cognitive frameworks. This is accomplished through the use of a number of different types of institutional work. Once created Institutions are not, however, static, and must be maintained through further institutional work.

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Figure 3 – The Institutionalisation Curve.

From Jennings and Greenwood (2003, p. 196), with modification after Scott (2008a).

The work to maintain an institution has received less attention than the creation of institutions. Indeed, authors disagree if this work is required or persistence is a feature of institutions (Scott, 2008a). The debate is centred on whether institutions are maintained, for example transmitted to new organisational members, through autonomous actions of others or through purposeful work by agents. Clegg et al. (2006, p. 926) warn against portraying organisational members as mere “cultural dopes” whose actions are predicted only by institutional norms. Scott’s (2008a) three categories of institutional work can be mapped to the three pillars of institutions, coercion to the regulatory pillar, normative work to the normative pillar and mimetic work to the cultural-cognitive pillar. This suggests that institutional work can indeed stem from institutional arrangements and not from purposeful action. However, Clegg (2006, p. 938) introduces the example of democracy to illustrate that even deeply embedded institutions are subject to maintenance through institutional work. Even though democracy is deeply embedded in western countries, it still requires purposeful work to maintain, for example during every election cycle there educating work, a kind of normative work, undertaken to ensure participation in the institution. To extend this example, in some countries where voting is compulsory and non-voters fined, coercive work is also undertaken to maintain the institution. Through institutional work agents seek to maintain institutions in which they have an interest. While some of this may happen autonomously, due to the effect of the institution on the agent, it is often purposeful. However, if this work is not undertaken, or institutional work is actively taken against the institution, then deinstitutionalisation may occur.

Deinstitutionalisation can be thought of as the reverse of the process of institutional creation. Actors can work to undermine the legitimacy of the regulative, normative and cultural-cognitive pillars and diffuse the claim of de-legitimation (Clegg et al., 2006, p. 945). Deinstitutionalisation can be undertaken with the aim of replacing the institution with a new one, or simply to remove the existing institution and can be carried out by agents within the institution or external to it.

Ad op tio n Time

Institutional Construction

Innovation Objectification Legitimation and Diffusion Fully Insitutionalised (Sedimented)

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The concept of the institution is important in explaining how the social constructs constrain the actions of organisations and individuals. It is easy to see institutions as independent and static. However, if we follow the agency account of institutions, they are constructed, maintained and destroyed by the purposeful acts of agents. These agents exist in the context of institutions and this also affects their actions, but we must be careful to not paint them as institutional automatons (Clegg et al., 2006, p. 926). This view of institutions does not account for some of the observed complexities of the institutional worlds, change from within an institution and the interaction and co-existence of multiple institutions in the same area.

2.5.2 Ins;tu;onal Change and Ins;tu;onal Entrepreneurship

One process not accounted for in the descriptions in the previous section is that of institutional change, short of their destruction. Institutional change occurs through the purposeful action of agents within the institution, known as institutional entrepreneurs (Hardy & Maguire, 2008, p. 198). Institutional entrepreneurship is “the activities of actors who have an interest in particular institutional arrangements and who leverage resources to create new institutions or to transform existing ones” (Maguire, Hardy, & Lawrence, 2004, p. 567). Institutional entrepreneurs may use the process of de-institutionalisation and institutional creation, or perform institutional work to modify the pillars of the institution. The concept of institutional entrepreneurship relies heavily on the agency account (Hardy & Maguire, 2008, p. 198). While the basic premise of institutional entrepreneurship is simple, the theory has struggled with describing the motivations of institutional entrepreneurs. One of the basic concepts of institutionalism is that institutions strongly influence individual behaviours through regulative, normative and cultural-cognitive means. This leads to the paradox of embedded

agency (Garud et al., 2007; Hardy & Maguire, 2008, p. 198). If an actor is truly embedded in

an institution, how can they envisage institutional change? Those empowered by institutional arrangements lack motivation, and those on the margins lack power. The paradox of embedded agency can be interpreted as a debate over the role of the naturalistic account versus the agency account (Garud et al., 2007, p. 961). Authors have attempted to solve this by introducing the concept of resource gathering (Battilana, Leca, & Boxenbaum, 2009, p. 68; Hardy & Maguire, 2008, p. 198). Hardy and Maguire (2008, p. 201) and Battilana et al (2009, p. 68) argue that institutional entrepreneurs seek to gather resources to allow them to enter into coercive institutional work. Battilana (2009, p. 81) also talks of gaining allies through discourse, similar to the use mimetic and normative institutional work as described by Clegg (2006, p. 227). Once an institutional entrepreneur has gathered sufficient resources they can enter into a negotiation based on their relative power and social position (Hardy & Maguire, 2008, p. 207). Alternatively, the institutional entrepreneur may seek to deinstitutionalise and construct a new institution with the gathered resources.

Accounts of institutional entrepreneurship tend to be actor focused and portray them as a heroic and almost universally successful (Battilana et al., 2009, p. 95; Hardy & Maguire, 2008, p. 210) using “rational, win-win problem solving” (Hardy & Maguire, 2008, p. 211). However, the entrepreneur may not be successful or not succeed at their original aim, and changed institutional arrangements are not always win-win (Hardy & Maguire, 2008, p. 211). There may be many successful institutional entrepreneurs who utilise rather more subtle techniques who simply do not come to the attention of researchers who have favoured the heroic accounts. Despite the rather black-and-white views of some researchers the unclear areas, institutional entrepreneurship gives a strong account of the mechanisms of institutional change.

2.5.3 Mul;ple Ins;tu;onal Logics

The traditional view of institutions is that they exist in sole possession of a particular field, and that actors are only influenced by one at a time. However, there is an increasing realisation that institutions may occupy shared or contested fields and actors may identify with multiple institutions or a single logic out of multiple present (Besharov & Smith, 2014, p. 365; Currie & Spyridonidis, 2016, p. 78; Greenwood, Raynard, Kodeih, Micelotta, & Lounsbury, 2011, p.

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319). Previous studies have focused on a single dominant logic out of two implicitly incompatible logics and on transitions between dominant logics. More recently there has been more emphasis on the interaction of multiple logics and coexistence of logics (Greenwood et al., 2011, p. 322). The ability of multiple institutions to co-exist has been explained through the negotiated order perspective (Currie & Spyridonidis, 2016, p. 79). Institutional actors may suspend advocacy for conflicting logics in order to give others prominence and maintain stability. Rather than a ‘final, negotiated peace’, this is a dynamic situation. Still, few authors have investigated the possibility mutually strengthening logics (Currie & Spyridonidis, 2016, p. 79) and there remains a long way to go to dispel the notion of logics being mutually exclusive and conflicting.

Multiple institutional logics are well documented in healthcare (Besharov & Smith, 2014, p. 364; Currie & Spyridonidis, 2016, p. 79; Greenwood et al., 2011, p. 335; van den Broek et al., 2014, p. 2). Traditionally the logic of doctors has been seen as the dominant institutional logic (Stein et al., 1990, p. 546). However, the rise of the professional healthcare manager has increased the power of the managerial logic (Currie & Spyridonidis, 2016, p. 80). Another important logic is that of nurses. While the logics in healthcare are often largely aligned around patient care, they have significant differences, which leads to competition, if not outright conflict (Currie & Spyridonidis, 2016, p. 80).

2.5.4 The Ins;tu;ons of Professions

The concepts of professions have strong parallels with institutional theory (Leicht & Fennell, 2014, p. 434). For example, the creation of professions is described in the same terms as the creation of institutions. Professionalisation, the way occupations gain the status of a profession, is described by Bloor & Dawson (Bloor & Dawson, 1994, p. 281) as “a sequence of often overlapping actions by members of the profession to gain control over their area of work”. This includes the development of professional standards, the standardisation of training and education and the creation of dedicated educational facilities (Bloor & Dawson, 1994, p. 281). This mirrors the normative, cultural-cognitive and regulative work of institutional construction. This has led to institutionalism becoming the dominant framework for analysing profession.

2.5.5 Predecessors: Func;onal and Power Theories

Prior to institutionalism, the dominant theories in the analysis of the institution of the professions, were those of functionalism and power (Muzio et al., 2013, p. 702). While these theories have been replaced, they do provide alternative perspectives and are useful in understanding historical accounts.

Functionalism is a strongly realist theory which seeks to explain roles and norms in societies (Holmwood, 2005, p. 809). The origins of functionalism were in anthropology and it was applied to a number of sociological fields (Holmwood, 2005, p. 809). It sought to explain the consequences of these roles and norms, which were sometimes termed institutions although not entirely the same as the institutions of institutionalism. At its core, functionalism held that all societies were comprised of the same set of functions, and there were immutable ‘social facts’ (Homans, 1964, p. 810). Concentrating on equilibrium conditions, functionalism had few explanations for societal change (Holmwood, 2005, p. 812). There was little room for agency in functionalism. Increasing criticism of functionalism in the 1960’s and 1970’s led to sociologists looking for new theories to frame the analysis of organisations (Muzio et al., 2013, p. 702).

The power or monopolist framework sought to explain power, conflict and change which functionalism ignored (Abbott, 1988, p. 15; Muzio et al., 2013, p. 702). Authors such as Freidson (1989, p. 425) placed emphasis on the pursuit of power and control over a particular field. In the case of a profession, the profession seeks to achieve ‘occupational closure’ (Muzio et al., 2013, p. 702) and restrict competition for work (Freidson, 1989, p. 426). This goal was achieved through a purposeful, political project (Muzio et al., 2013, p. 702). Again, this

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approach faced significant criticism, especially for its reliance on a few cherry-picked examples (Muzio et al., 2013, p. 702).

The theories used in the analysis of professions prior to the advent of institutionalism attempted to explain behaviours with a naturalistic account and a purely agent-based account. Both were displaced due to their inability address obvious issues, such as the role of power or explain all cases. However, many historical accounts were written from these perspectives and understanding them is important to understand these accounts’ context.

A Model of Professional Change

The concepts of professions and the professional project together with the institutionalism can provide a model for professional change. We propose a new model for the change of organisational environments by institutional entrepreneurs in an environment of conflicting institutional logics, this is illustrated in Figure 4.

When professions are in an environment with multiple institutional logics where the prevailing institutional logic conflicts with their own, they engage in institutional entrepreneurship to bring about change. This then follows the pattern of institutional entrepreneurship, resources are gathered so that the profession can enter into institutional work to generate new norms, symbolic systems and regulatory powers which can be used to renegotiate the institutional order. Of course, this is not a linear or even progression, and cycles of resource gathering and institutional work may occur before negotiation, or they may fail to gather sufficient resources or conduct substantive enough institutional work to enter into negotiations at all. Indeed, the most probable pattern is continuous resource gathering and institutional work, followed by small changes to the institutional order, resulting in a return to resource gathering to continue the project.

Figure 4 – A Model of Professional Change

Organisa9onal / Ins9tu9onal Environment Professional Project Resource Gathering Ins9tu9onal Work Ins9tu9onal Order Re-nego9a9on

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Healthcare is a field in which multiple institutions interact and conflict. We have seen that each institution, doctors, nurses, managers and many others, have their own logics, resources and institutional goals. In healthcare, we contend that this cycle occurs as follows. The prevailing institutional logic in healthcare could be described as a negotiated mix of the medical logic of the doctors and the managerial logic of healthcare managers. This conflicts with the “separate but equal” logic of nurses (Salhani & Coulter, 2009, p. 1223). This has led to a long period of resource gathering and institutional work. Possible examples of this are increasing education of nurses, which serves to increase social capital a resource, and theorising new responsibilities through professional publications, which is a form of normative institutional work. Over time the institutional order has been slowly renegotiated, which is evident in the increasing status and independence of the nursing profession.

Furthermore, we contend that participation in continuous improvement activities may be both resource gathering and institutional work. Continuous improvement activities disrupt organisational order, and can give access to positions of power, but they can also allow the establishment of new regulative structures as well as new norms and symbolic systems. Thus, in the context of inter-professional interplay, continuous improvement activities are both resources and methods to gather further resources.

Bringing Together Ins;tu;ons and Professions

The purpose of this thesis is heavily connected to the inter-relationships of professional groups. However, defining a profession is a particularly hard task. While researchers initially concentrated on the traits found in Anglo-American legal and medical professions, definitions have broadened. Researchers do agree which occupations are professions even if their definitions vary. Important concepts for professions are those of professional self-identity and the professional project. Professionals identify with and through their profession, particularly in the medical field. Professions also seek to improve their social and professional status and do so through purposeful work of a professional project.

Effective management of organisational change relies on a combination of leadership and employee involvement. Some continuous improvement methodologies stress the importance of one or both of these elements. However, change is often poorly managed, with many change processes failing. Change management frames these issues as a leadership issue. Resistance to change is the most common reason for failure. Approaches such as framing change in a manner that matches employee aspirations can help to reduce resistance.

The dominant sociological theory for analysing the professions is institutional theory. Functional and power theories are found in older accounts, but have fallen out of favour. Institutional theory holds that there exist social constructs of norms, values and regulations which influence the behaviours of individuals and organisations. While the traditional view of institutions is that they exist in sole control of an area, it is now recognised that several institutions can co-exist or compete. The extent to which agency, that is the conscious actions of individuals and groups, can affect institutions is a matter of debate. However, accepting a high degree of agency is important in describing change in institutions via institutional entrepreneurship. Institutional entrepreneurs seek to change institutions via a process of resource-gathering which allows them to impose or negotiate changes which they desire. Despite the complexities, institutions and institutional entrepreneurship give a compelling account of the actions of professions

The existence of the ‘professional project’ to improve social and professional status is well documented. This is a project of institutional change through institutional entrepreneurship. If institutional entrepreneurship is a process gathering resources, then it is possible that involvement in continuous improvement constitutes one of these resources or is institutional work. Therefore, involvement in continuous improvement may be driven by the ‘professional project’. This raises the question:

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Research Question 1 – How does the ‘professional project’ of nursing affect nurses’ motivations to become involved in continuous improvement programs?

If involvement in continuous improvement constitutes a resource for enacting institutional change, then it may have resulted in some progress towards the goals of the ‘professional project’. This leads to the question:

Research Question 2 – How has involvement in continuous improvement programs affected the status of the nursing profession?

Figure

Table	of	Contents	 Acknowledgements	 i 	 Abstract	 ii 	 Figures	 v 	 Tables	 v 	 Appendices	 v 	 1 	 Introduc:on	 1 	 	 Background	 1 	 1.1.1 	 Con9nuous	Improvement	 1 	 1.1.2 	 Con9nuous	Improvement	in	Healthcare	 1 	 1.1.3 	 Inter-professional	Rela9onsh
Figure 1 – Reasons Change Programs Fail (Giniat et al., 2012, p. 85)
Figure 2 –  A Model of the Main Tasks and Roles of Nurse-Leaders During a Change Process (Salmela et al.,  2012, p
Figure 3 – The Institutionalisation Curve.
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References

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